[Mineral and bone disorder in chronic kidney disease : Critical appraisal of pharmacotherapy]

Mineral and bone disorder (MBD) in chronic kidney disease (CKD) is associated with increased cardiovascular calcification and mortality. Pharmacological interventions for MBD in CKD are characterized by inconsistent data and a wide spectrum of (sometimes costly) treatment options. The objective of this article is a guideline-oriented overview of the differential indications for pharmacotherapy considering cost-effectiveness.

The serum phosphate concentration in patients with CKD stages 3-5 with a glomerular filtration rate (GFR) of < 45 ml/min should be kept within the normal range. Currently, under consideration of cost-effectiveness, calcium-containing phosphate binders and combinations of calcium acetate with magnesium carbonate are the preferred treatment options. Phosphate binders free of calcium are indicated in patients with high normal or elevated serum calcium levels. Low vitamin D concentrations in CKD stages 3-5 should be treated under consideration of serum calcium and parathyroid hormone (PTH) with calcidiol (25-cholecalciferol) and in dialysis patients (CKD 5D) with calcitriol (1,25 dihydroxycholecalciferol, activated vitamin D). In CKD the PTH levels should be kept in the range of 2-9-times the upper limit of normal levels. This is achieved by administration of phosphate binding drugs, activated vitamin D, calcimimetic compounds and parathyroidectomy. In CKD stages 3-5 patients metabolic acidosis with < 22 mmol/l serum bicarbonate should be treated with oral sodium bicarbonate.

In MBD of CKD patients an individualized pharmacotherapy which is closely guideline-oriented is required in order to achieve cost-effectiveness.